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Kate Kirk
Kate Kirk Lecturer in Organisational Behaviour in Healthcare, University of Leicester.
I work across the Medical School and Department of Population Health Sciences.
I am a member of the Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group and specialise in qualitative methods to understand organisational behaviour in healthcare, ethnography and researching sensitive topics in healthcare. I am a Registered Nurse by clinical background and specialise in emergency care.
I noticed how I used the phrase ‘warzone’ quite a few times, when you’ve got trolleys everywhere … full of patients and you don’t know where to turn next. What to do for whom next, and I have said it’s like being in a warzone because you can imagine it. That’s what it would be like in a field hospital … what do I do next? You know it’s dangerous but you’ve just got to do the best you can do. And I’ve heard other people use that term as well. Just how it makes you feel but something kicks in and you just get on with it.
This was how one nurse in her 40s described an Accident and Emergency (A&E) department to me, and it sounded all too familiar.
The resuscitation area in the emergency department is a hive of time-critical activity as staff weave around one another at pace. The sheer din is intense: a symphony of alarms, voices and crying out – all varying in pitch and volume, competing with one another. The bays are awash with wires, pipes, medical equipment and pumps to give various medication.
This is the norm. But some nights will always stand out above the others. Once, while I was on shift, a three-year-old girl in a nearby resuscitation bay was receiving treatment for meningitis. Following a substantial and sustained attempt at resuscitation by the paediatric team, she died.
I wasn’t caring for her directly, but it was apparent from the noise how the treatment was progressing and when, ultimately, it was unsuccessful. The screams and cries of grief from the girl’s parents were heard above all other noise when staff broke the news to them that their child was dead. It was unforgettable.
Many of the adult patients were too unwell to know what was going on. So, despite the communal awareness among staff of the enormous distress close by, we carried on caring for our other patients, offering them the “reassuring face” and warmth they expected. I stood behind one of the curtains for a few moments and swallowed hard at the sounds of the suffering. And that was it. Sadness and distress at the death of a child had to be suppressed for the sake of the other patients.
On the drive home I reflected on the emotional complexity it requires to be a nurse. The need to hide sorrow while juggling great workloads, the pressure of organisational targets and other patients’ seemingly less critical needs requires intense effort and emotional control. That effort is exhausting and draining.
This tragic incident was just one of many similar experiences I have encountered over my 11-year career as an A&E nurse. Heartbreaking and emotionally complex stories like this happen every day in A&Es up and down the country. Nurses have to conceal myriad feelings as standard just to get through their shifts. This includes harrowing, disturbing and traumatic emotion as described in the story above, but also fear and anxiety when they feel overwhelmed and have to deal with aggressive situations. Nurses experience joy and relief when a patient recovers against the odds but frequent guilt and shame at being unable to deliver the standard of care they desire.
The exploration of emotional labour in emergency care has underpinned my subsequent research career. It has motivated me to explore and support this under-recognised area of nursing practice.
“Emotional labour” is a theory coined by sociologist Arlie Hochschild who defines it as “the management of feeling to create a publicly observable facial and bodily display”. When that toddler died of meningitis, myself and the other nurses did our own emotional labour by suppressing our true emotions to ensure the other patients in our care felt reassured. In other words, we remained “professional”.
But the nurses I spoke to are not only dealing with emotions related to grief and bereavement. Because of the crisis facing the NHS, many feel they can’t do their job properly and so have overwhelming feelings of guilt too. A male nurse in his 30s told me:
You can’t be the sort of nurse you might want to be … You can’t nurse people properly in the ED (emergency department) … You don’t have the staff or facilities to do that and it’s just getting worse … I think it’s one of the major things that make it a hard place to work because you feel that you’re not doing the best for the people you’re looking after … it can actually grind you down. As nurses, you want to care for people. You want to make a difference.
NHS in crisis
A recent analysis by The Kings Fund showed the extreme pressure the NHS is under. More patients than ever are experiencing delays in cancer diagnosis and treatment and longer waiting times in “non-urgent care”.
These pressures have an impact on patients, but also affect those tasked with delivering care. Nurses are quitting in record numbers. By 2030-31 half a million extra healthcare staff will be needed to meet the pressures of demand – a 40% increase in existing workforce. Health and social care staff are exhausted and the workforce is depleted. The negative impact of this crisis cannot be underestimated for both staff and patients.
When nurse staffing is short or lacking in the required skills due to issues like high staff turnover and sickness, research shows that patient mortality is higher and patient experience is poor.
Nurses working in short-staffed areas are twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care in their hospitals. This becomes a vicious cycle as these experiences fuel more staff to leave.
Sickness absence rates in the NHS are higher than in the rest of the economy and 47% of staff felt unwell in the last 12 months as a direct result of workplace stress. One study has shown levels of Post Traumatic Stress Disorder similar to those experienced by soldiers in Afghanistan.
A recent evaluation found that poor mental health and wellbeing among medical staff is costing the NHS about £12.1 billion per year.
Accident and Emergency
In England, NHS patient attendance to A&E has followed an upward trajectory over the last 70 years. In 2019-20 there were 25 million attendances, compared to 21.5 million attendances in 2011-12.
Patient attendance has been growing exponentially in the last ten years. This, together with rises in patients who need admitting to hospital for routine care, fewer hospital beds and staffing pressures has resulted in unsafe patient overcrowding in A&Es. Research has shown how overcrowding increases adverse clinical outcomes including death, medical error and decreased patient satisfaction.
The most recent figures for 2022-23 show the worst A&E performance (waiting longer than four hours) on record.
Perhaps unsurprisingly then, those working in emergency care are more likely than other healthcare workers to experience poor wellbeing, suffer psychological illness and to quit their jobs.
Nurses open up
According to the Royal College of Physicians, NHS staff are the greatest asset of the NHS and are fundamental to delivering high-quality care. Staff go “the extra mile” as standard: they work without breaks, come in on their days off and often stay unpaid, long after shifts have finished.
My PhD aimed to understand the experiences of nursing staff in A&Es and how they managed their emotions to cope with these challenges and still meet patient expectations. This is critical because emotional labour, in particular, is linked to wellbeing and burnout.
I worked with a team of academics to undertake an ethnographic observation study across two large NHS trusts in the UK. This involved 200 hours of observation and 36 in-depth interviews. We spoke to A&E nurses of all seniority and support staff in both organisations. We found that the nursing staff “did” intense emotional labour routinely in their work. As one male nurse in his 30s explained:
… you know, you see quite a lot of bad things. You deal with a lot of complex things and … you do have to put up a front, a very professional front, and you have to deal with different levels of communication as well. You’ll get someone with mental health problems one minute, get someone with a broken finger the next minute, someone’s collapsed … Then you just have to mould yourself into a different personality … to communicate with [each patient], to get on their level of need … you’ve got to go from zero to hero, as far as I’m concerned … Never knowing somebody to doing something really, really intimate … So you’ve got to get to know them really quickly, for them to be able to trust you.
The nurses adapted their emotional response to support a vast spectrum of patient need. Among these complex and intense emotions, we heard examples of nurses who felt scared, guilty and endless examples of nurses being short on time and resource, feeling stressed, and grieving over patients who died. They hid their true feelings to make sure their patients felt safe and to build trust – whatever the circumstances. They moved at pace between groups of patients and adapted their appropriate “professional” response.
We collected data over a six-month period and found that the nurses used various metaphors to describe experiences of managing their emotion in A&E. We found some key themes.
Guilt and shame
Nurses described to us how sometimes the environment can feel overwhelming, using that “warzone” phrase to explain their experiences. This sense of relentlessness and “combat” has implications for the nurses’ emotional labour too. Their nursing values (related to providing care and compassion) are conflicted with the realities of contemporary practice. The standards of care possible amid the operational pressures don’t reflect these nursing values (built on warmth and reassurance).
The nurses I spoke to weren’t able to deliver the quality of care they wanted to. This means they needed to suppress the associated frustration and guilt. There was a sense of genuine sadness and even shame that they couldn’t give their patients the time or connection they longed to.
This former nurse said one incident in particular “changed her outlook on A&E” and led to her thinking, “I can’t work here anymore”.
It was a really, really busy winter day … trolleys were stacked … and right in the middle I had a little old lady in her 90s who suddenly deteriorated and I could do nothing but stand in the middle of all the trolleys, in front of all of those people, holding her, shouting for help. I just thought that if that was my grandmother, I’d be disgusted.
Assembly line
Instead of meaningful patient and nurse relationships, the care delivered in A&E often feels transactional and lacking emotional connection. Interactions were quick and task-based. Again this results in the nurses feeling dissatisfied and often guilty. Jill Maben, a professor of health services and nursing, found that when nurses are unable to deliver the care they want to, it doesn’t line up with their values. This disconnect (between values and reality) can be a reason why nurses leave the profession.
The clinical realities of the nurses work went against their deep moral values and the desire to care. This was reflected by many of the nurses I met, including a female nurse in her 40s, who said:
I’ve actually used that term assembly line – it’s like a production line of patients … you’ve got [ambulance] crews coming in constantly … You take handover from the crew, do the basics, move on to your next patient. Take handover, do the basics, move on to your next patient. You might not even see that patient again … it means there’s a definite lack of care there … I go home feeling very unsatisfied because you’ve not cared for people, you’ve just checked their observations, given them any immediate treatment they need, but the actual caring aspect of it, you’ve not really done any of that.
For some of the A&E nurses interviewed in the study, the inability to deliver the standard of care they wanted to was unmanageable and they left. One told me she quit because A&E was so busy it meant ignoring some people who were waiting long hours. She said:
I think you need to be quite stony-hearted because it’s a hard place to work … I care too much. I can’t walk past somebody that says ‘can you help me?’ and unfortunately you don’t have time. In A&E, you don’t have time to stop for every person who says ‘excuse me’. You need to be able to walk past people …
Stress and fear
Sometimes the nurses said they were scared: scared of the overwhelming workload as well as the threats and intimidation they received from patients. One of the nurses, in her early 20s, described how she “put on a front” to her patients. She did this to hide any anxiety around her inability to cope. She was protecting her patients from her true emotion and as a result, making sure they felt safe:
I suppose from the outside it could appear that you’re managing well, you’re getting to your patients, you’re putting on a front, you’re smiling, you’re happy. You present yourself. You tell them what the plan is, what’s going to happen, what to expect next. Then you’re whisking off to take the next patient or moving on to another area. So, yeah … patients’ or relatives’ perception could be that it doesn’t look as busy because they don’t see what’s going on behind the scenes. They don’t see what resus [resuscitation] is like, that there’s minus three beds in there … Or the walk-in side … there could be probably five or six people in the waiting room wanting to know why they’ve not been seen straightaway because it doesn’t look busy, whereas resus is just behind the doors and there could be massive traumas going off.
She said it was important not to let patients see that they were “stressed and flustered” because “it gives them reassurance … to show patients that you’re confident and you can get on with it”.
Again the nature of this emotional labour (this time suppressing fear and anxiety) is guided, in part by the need to protect and reassure patients under their care. Another nurse, in his 30s, added:
…you’re actually like a parent to everybody. You’re everybody’s mum or dad. So on the surface you do have to look calm and you have to look like you’re in control because they’re vulnerable and you can’t be panicking because it’s just not going to solve anything, whereas underneath you might not have a clue what to do, but you have to come up with something and you might be crapping yourself … it’s just a mask, isn’t it?
For some, the extraordinary feeling of stress involved is overwhelming but the nurses stay calm and professional outwardly, as described by a female nurse in her 30s:
It’s a mixture of stress. Sometimes you just feel like you just don’t know where to start. Sometimes in the environment where it’s overcrowded like that, you can feel very enclosed and it can feel quite pressurised because … you can feel like everyone is looking at you.
She added that the same amount of pressure and noise could amount to “torture” for some people.
But sometimes the stress was related to fear and anger when dealing with an aggressive and abusive patient. Again the nurse’s emotion remained hidden and out of sight of the patient and others in the waiting room. One nurse described an incident on a particularly busy night with a man who was getting tired of waiting with a minor injury.
She offered him assistance, as he was struggling to walk. But he shouted at her in front of a full waiting room, including children: “Why don’t you just fuck off and die?”
The nurse was shocked. The entire waiting room was staring back at her. She said she couldn’t speak and that her “blood was boiling” but she was also frightened. She couldn’t engage with him so she walked away, afraid she would shout back or cry if she tried to speak. “Had I been outside of work, I wouldn’t let people speak to me like that,” she said.
She added that if those unruly and abusive patients were shown a baby being resuscitated in the next room they might rethink their behaviour and show more respect.
Grief and trauma
But all feelings must be managed, even sadness and grief – perhaps these emotions above all.
If you came into [A&E] and a nurse started blubbering because of your story, what would you feel like as a patient? So, we probably are good at emotions but actually we’re good at not showing them. It doesn’t mean to say we don’t feel them … The more competent you become as a nurse, the more you actually learn that you have to suppress that … If you get a baby that comes in and the parents are screaming and crying, they don’t want the nurse doing the same thing. They want the nurse to be efficient, to know what they’re doing and to assist them. They do not need an emotional wreck to be dealing with them.
This female nurse said that managing emotions like this meant some nurses might sometimes come across as “hard” and “cold”.
But being able to relate personally to the patient or their family, although helpful for the patient, can take a heavy toll on the nurse. One nurse got upset when telling me about the time she was pregnant with her little boy and was resuscitating a baby.
Yeah. That was a baby. It sticks with you. It definitely does. I was looking after another one … that was having seizures. It was a one-year-old little one in resus, and when I finished my shift, I’d gone home, but it was on my mind all night and I was wanting to ring back and check. Obviously, I’ve got no connection to that little one … you can relate it to your own children as well, put yourself in those parents’ shoes.
Compassion fatigue
Operational pressures in A&E and elsewhere in the health service squeeze the time nurses have with their patients. The fact many are unable to deliver the standard of care they long to contributes to nurses leaving the profession as described above.
And those nurses who stay can become so burned out that they can suffer with compassion fatigue: a protective mechanism in which nurses become emotionally “shut down” and as a result, can fail to notice and respond accordingly to trauma and suffering. This shows that the health – particularly the mental health – of nurses and doctors can directly impact patient care.
We need to understand the emotional complexity of nursing and other healthcare work. In understanding it, we can value it.
Nurses are not angels, they are human beings, with the accompanying full spectrum of emotions. At their best, they can offer life-changing support and compassion. But they need the resources and support. There is only so much stress, fear, grief and trauma a person can cope with before burning out completely.
This article is republished from The Conversation under a Creative Commons license. Read the original article.
